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Surgical Conditions – Obesity Surgery

If you have tried diets, cures, tablets or medicines and they haven't helped you lose and maintain a healthy weight, option may be an operation to artificially reduce the amount your stomach can hold and decrease your appetite.

Laparoscopic Gastric Banding :: Gastric Bypass :: Gastric Balloon
Bilio Pancreatic Diversion BPD :: Sleeve Gastrectomy

Biliopancreatic Diversion History, Technique, Side effects and Complications

This procedure was developed by Prof Nicola Scopinaro in Italy and was introduced in 1979. It combines the benefits of restriction and mal-absorption. Since its introduction, over 10,000 cases have been carried out world-wide with excellent results. Prof Nicola Scopinaro introduced Biliopancreatic diversion over 20 years ago and since then he has performed in excess of 2300 cases. The operation combines initial restriction of food intake with a major fat and starch malabsorption. The malabsorption occurs without the side effects of the small bowel bypass procedure as the biliopancreatic limb of the procedure conducts bile and pancreatic fluid to the small bowel and is functional. The flushing of this loop with bile and pancreatic juices prevents the stagnation and bacterial overgrowth that led to septic problems with small bowel bypass. The weight losses achieved by this procedure are the best for any available weight loss procedure and weight regain is less likely to occur because of the inability to absorb more than 25% of ingested fat and starch. Prof Scopinaro claims a long-term weight loss of 73% of excess body weight. My experience would support this result although there is a spectrum of weight reduction with some losing too little and some too much. It is also possible to regain some weight in the order of 7-10 kg and at times more so. The procedure in my experience is very effective but not infallible.

This is the original Scopinaro procedure. The lower stomach is removed leaving a pouch of between 250 and 400ccs. The duodenum is closed over. The small bowel is measured backwards from the point where it joins the large bowel or colon a distance of 250cms and the small bowel is cut across at this point. The lower divided end is joined to the stomach pouch. The bottom end of the upper section is joined to the lower loop so as to make a new opening 50cm from the point where it joins the colon.

Figure 1 –The Scopinaro Procedure:

The effect of the procedure is threefold:

  • The patient is initially only able to eat a very small amount of food. As time progresses,usually by 12 months from the time of surgery, the patient will be able to consume regular sized meals
     
  • The food passes through only 40% (275cm) of the small bowel and so reaches the colon much more rapidly than normally and so has less time to digest fully
     
  • The bile from the liver and the pancreatic juice from the pancreas, two of the most important digestive juices, have only 1/10 of the normal time to digest the food in the small bowel as they enter the bowel only 65- 75 cm from the caecum. This results in failure to break down fats, starches and proteins so that they absorb poorly. Only approximately 25% of these are absorbed. This means there is a major alteration in the patient’s digestive processes with controlled mal-absorption of nutrients. The poorly digested food passes rapidly through the colon and is lost to the system with resultant initial weight loss and long term weight control

    Please refer to the above diagram as this technique is complex and difficult to understand

After one year there is compensatory enlargement of the stomach and small bowel that allows weight loss to stabilise. Enough mal-absorption remains to prevent major weight regain in most cases.

Prof Scopinaro has reported excellent long-term weight control over a ten year follow up. Additional benefits include control of weight related co-morbidities such as diabetes, sleep apnoea, arthritis and the reduction of raised cholesterol and triglyceride levels to normal.

The surgery is more major than with gastric banding procedures and is not, in my hands, a laparoscopic procedure. It requires a long upper abdominal incision. The main complications at the time of surgery are:

  • Leakage of the anastomoses between stomach and intestine resulting in abscesses or peritonitis
  • Haemorrhage
  • Pulmonary embolism
  • Myocardial infarction
  • Pneumonia
  • Pancreatitis

Late complications and side effects include:

  • Vitamin deficiencies
  • Calcium deficiency resulting in bone softening
  • Protein malnutrition
  • Diarrhoea
  • Malodorous bowel motions and flatus
  • Incisional herniae
  • Small bowel adhesions

Some of these are serious complications and could be life-endangering. There is a 1.5% mortality rate.

The recovery period for this procedure is 3-6 months and it is common for patients to feel weak and have periods of nausea and even vomiting during this time. Later, the main complaint of patients over the first year is of malodorous frequent loose bowel actions. It is common for patients to have their bowels open three times of a morning and once later in the day.

One of the major advantages is that by the end of one year the patient can eat normal sized helpings. Patients can eat most foods. However, fatty foods cause oily diarrhoea and should be strictly avoided. Patients should eat protein first and make sure they consume at least 100gm of good quality protein daily so as to avoid protein mal-nutrition. Sugars are still absorbed and can lead to weight regain if consumed in large amounts. At times, sweet high-calorie foods cause sweating and tachycardia, a condition known as “dumping”. This causes aversion to sweets, which aids weight loss. This does not occur with all patients. Strict avoidance of fat in the diet also improves the odour problem. Spices should also be avoided as these increase the odour problem and patients must avoid sugars as these can cause weight regain. Deficiencies of protein, calcium, iron and fat-soluble vitamins can occur as mentioned above. Eating reasonable amounts of meat and dairy products can prevent protein and iron deficiency. Vitamin and calcium supplements should be taken regularly. Occasionally admission to hospital for intravenous protein feeding or infusion of vitamins or iron has been necessary. Reversal of the surgery has been required in 2% of cases. By the end of the of the first year, bowel actions have stabilised at three-four per day, protein absorption has improved and the patient is usually eating a normal meal without vomiting or heartburn.

Drs Douglas Hess and Piceau Marceau, have modified the procedure by performing the gastrectomy so as to convert the stomach into a long tube with the pylorus preserved (Fig.2).

Difference between the two techniques is that the length of the common limb of the small bowel is longer with this technique than with the Scopinaro. The common limb is the length of small bowel between the junction of the biliopancreatic limb and the alimentary limb carrying food from the stomach and the point where the small bowel enters the large bowel. Prof Scopinaro routinely leaves a 50 cm limb whereas Dr Hess varies the length according to the length of the entire small bowel. He calculates 10% of small bowel length and makes this his common limb length. It may vary between 50 and 100 cm. It is claimed that this procedure known as biliopancreatic diversion with duodenal switch has benefits over the Scopinaro technique. These include

  1. The prevention of stomal ulcers (peptic ulcers where the stomach pouch is joined to the small bowel) quoted by Scopinaro as occurring in 8.3% of cases.
  2. The patients having more normal bowel function.
  3. Bad breath does not seem to be a problem.

This Is My Preferred Technique Of Biliopancreatic Diversion

Postoperative Diet

BPD patients are initially very restricted in their food volumes but by twelve months they should be able to eat a normal volume of food without vomiting or heartburn.Initially they should concentrate on drinking adequate fluids.Once they can drink well they should move onto helpings of high protein low fat puree foods in small quantities.6 small helpings per day should be taken.As intake improves over 3-6 months normal food can be consumed. Most food types can be enjoyed but it is important that fats be avoided.  These do not absorb, passing through the bowel and causing diarrhoea and odour.  Too frequent stools cause loss of other nutrients and may cause long-term hypoproteinemia.  It is essential therefore to avoid too many fats.  Although patients absorb little fat and only small amounts of starch, they can absorb sugars.  Too many sugars in the form of sweets, alcohol or fruit may result in weight regain. 

Weight regain is possible after BPD and patients should be aware that this is so.  The procedure is not infallible

The loss of nutrients after the procedure is the principal side effect.  The inability to absorb fats also interferes with absorption of the fat-soluble vitamins A, D, E & K.  Bypassing the duodenum, the first part of the small bowel after the stomach, can cause iron deficiency with resultant anaemia.  Because of the difficulty maintaining iron levels, any blood loss i.e. from heavy periods or haemorrhoids, should be controlled and no blood donations should be made.  Similarly, the upper small bowel is the site of absorption of calcium and failure to absorb calcium may result in osteoporosis or osteomalacia. 

For these reasons it is vital that patients take life long vitamin, calcium and iron supplements. 

 I recommend a number of vitamin and mineral regimes

  1. A  product called Vita4Life which has high levels of Vitamins A, D, E & K, 2000mg of calcium and 300mg of ferrous fumarate as well as other trace elements and vitamins.  It can be obtained over the Internet from the USA.  The address is www.vita4life.net.

  2. 2 VitaBDEK tablets from Technipro,2 Centrum or other multivitamins,1000 mg of calcium and 1-2 Fergon tablets.

Blood levels of Vitamins B12, Folate, A, D, E, & K as well as a full blood count, liver function tests, lipid, calcium, magnesium and iron levels should be checked six-monthly for at least the first three years postoperatively   

Get ˝ Hour Of Sun Per Day It Helps Your Vit D Levels

If deficiencies develop despite these supplements then injections or infusions of iron and vitamins may be necessary.  On occasions it is necessary to reverse or modify the procedure.  The reasons for having to do this have included intractable diarrhoea, nausea,  protein malabsorption and recurrent small bowel adhesions.  The procedure can be reversed by placing the small bowel back in its normal order or modified by changing the join between the alimentary and common limbs so that the alimentary limb is increased in length to 3.5 metres from 2 metres.

Results achieved in my series of cases:

Good average weight losses have been achieved with close to 75% of excess body weight being lost.  The results are shown on the graph below.


The Downside of the Surgery

Despite the good average weight losses, some patients are dissatisfied with the amount of weight lost and others have lost too much and become malnourished.  I cannot therefore promise that all patients will lose 75% of excess bodyweight.  They will however lose substantial weight and importantly, medical illnesses such as diabetes, sleep apnoea, hypertension and arthritis of the weight bearing joints are markedly improved therefore improving general health, self-esteem and hopefully longevity.

The procedure is a major and complex one and patients undergoing it are high risk.  They are technically difficult to operate on and are at risk of developing deep venous thrombosis, pneumonia and wound disruption.  I have performed in excess of 200 cases over a 10-year period and the serious complications I have experienced are summarized below.

Serious problems in 200+ cases over 10 years
 


1.

 


Fatal pulmonary embolism


2 cases


2.

 


Death due to small bowel ischaemia following pancreatitis


1 case


3.

 


Fatal septicemia ? cause 6 months postoperative                      


1 case


4.

 


Leaks causing abscesses


3 cases


5.

 


Diarrhoea or hypoproteinemia requiring revision


3 cases


6.

 


Necrotising pancreatitis requiring drainage (patient died 4 years post-op)


1 case


7.

 


Reversals due to diarrhoea, hypoproteinemia or odour


6 cases


Side effects of the malabsorption. The incidence of these problems is as follows


1.

 


Low vitamin A


17.7%


2.

 


Low vitamin D


26.2%


3.

 


Low vitamin K


24.4%


4.

 


Low iron


28.0%


5.

 


Low protein


8.5%


6.

 


Low calcium
 


1.8%

These problems can be avoided by religiously taking vitamin and mineral supplements and having levels checked six-monthly. Get some sun exposure.

Vitamin D Injections Are Available From My Office If Your Vitamin D Levels Drop And Cannot Be Restored By The Above Methods

General side effects

I have recently surveyed 196 patients who have had the surgery performed more than one year ago.  130 replied to the survey in which they were asked specific questions about the side effects.  The results were as follows.
 


1.

 


Do you experience bouts of tiredness?


Yes – 63%


2.

 


Do you feel your energy levels are poor?


Yes – 30%


3.

 


Do you have bouts of nausea?


Yes – 18%


4.

 


Does the odour of the stools and flatus worry you?


Yes – 53%


5.

 


Have you regained any weight at all?


Yes – 48%


6.

 


If you eat fats do you experience oily incontinence


Yes – 41%


7.

 


Have you experienced bad breath?


Yes – 30%

So is it all worth it?

I was pleased to find that despite the apparent high incidence of annoying side effects that 85% of patients replied that they were happy with the results of the procedure and 95% said that they would recommend it to patients with severe non-responsive weight problems.

What can patients do to improve the outcome and avoid side effects?


1.

 


Stick to a rigid high protein low fat diet.  Always eat protein first.


2.

 


Avoid sugars and alcohol.  These can cause weight gain and pancreatitis.


3.

 


To reduce the odour in the stools, minimize intake of fats and spices.
Try taking 2 zinc tablets a day.
There is also a faecal deodorant called Devrom available from
www.parthenoninc.com that some have found helpful.
 


4.
 


Take your vitamins and minerals religiously.  Make sure the supplements are high in
vitamins A, D, E & K.  Most multivitamins contain only B complex and C. 
These are not suitable after BPD surgery as the water-soluble vitamins they
contain, are not a problem with this type of procedure. 
Patients should take 2000 mg of calcium and 300 mg of iron.


5.

 


Stop any blood loss such as bleeding haemorrhoids or from heavy periods. 
Do not donate blood.  Iron deficiency may otherwise result.

 


6.

 


Check blood levels of haemaglobin, iron, calcium, Vitamins
A, D, E, K, B12, folic acid and LFTS six-monthly and have copies sent to me.

 

What can be done to help side effects?


1.
 


Bouts of windy diarrhoea.


Try Flagyl 400 mg tds and Imodium.


2.
 


Chronic diarrhoea.


Try Creon Forte tds with a stool thickener such as
Agiofibe taken dry.


3.
 


Low protein levels.


High protein drinks such as Ensure or Vivonex. 
Resource protein powder is useful. 
Creon forte pancreatic enzyme tablets with each meal
will boost protein absorption.

 


4.
 


Low vitamin D levels.


If these do not respond quickly to increased oral dosage,
I suggest a vitamin D injection. Get some sun exposure.
 


5.
 


Bad breath.


Try mint flavoured sprays or mouth washes. 
If this does not help try Flagyl 400mg daily.
 

Severe Abdominal Pains

The biliopancreatic limb of the small intestine does not contain gas and therefore, cannot be seen on a plain X-ray of the abdomen.  This is the usual way of diagnosing a small bowel blockage which is one of the common causes of severe stomach pain after surgery.  Alert your doctor to this and say that you need an ultrasound or CT scan to show if you have a blockage.  If so, you may require urgent surgery to relieve the block.  Ask him or her to contact me for clarification.

Click here for for Patient letter on Biliopancreatic Diversion for Obesity

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